CMS Schedules May 2015 Meetings on HCPCS Applications

CMS has announced that it is holding series of meetings in May 2015 to discuss pending  Healthcare Common Procedure Coding System (HCPCS) applications. The meeting dates are as follows:

May 7 & 8 -- Drugs/Biologicals/Radiopharmaceuticals/Radiologic Imaging Agents
May 21 & 22 -- Supplies and Other
May 27 -- Durable Medical Equipment (DME) and Accessories; and Orthotics and Prosthetics (O&P)

Deadlines and instructions for speaker and general registration and submission of comments are set forth in a notice to be published tomorrow.  Additional information, include preliminary coding determinations, will be posted in advance of each meeting at the CMS HCPCS website

CMS Invites Applications for Oncology Care Model

CMS is soliciting applications for organizations to participate in a new Oncology Care Model (OCM), which will test performance-based Medicare payment for episodes of care surrounding chemotherapy administration to cancer patients beginning in 2016. The model features a two-part payment system for participating practices: (1) a $160 monthly per-beneficiary-per-month payment for the duration of the episode, and (2) the potential for a performance-based payment for episodes of chemotherapy care to encourage practices to lower the total cost of care and improve care for beneficiaries during treatment episodes. The OCM is expected to start in the spring of 2016, and will last five years.

Hospital Engagement Network Contract Solicitation

CMS is requesting proposals for Hospital Engagement Network (HEN) contracts from qualified entities to work on reducing preventable hospital acquired conditions and readmissions through the Partnership for Patients initiative. HENs will engage the hospital, provider, and broader care-giver communities to quickly implement tested, evidence-based, and measured best practices in order to reduce hospital-based harm and preventable readmissions. 

CMS Raises the Bar for Nursing Home Quality Ratings under "Nursing Home Compare 3.0"

CMS has made revisions to the measurements used in the Nursing Home Compare Five Star Quality Rating System that have resulted in a decline in the star rating for about one-third of nursing homes. Specifically, on February 20, 2015, CMS added quality measures regarding the use of antipsychotics, revised the calculation of nursing home staffing levels, and strengthened the criteria for nursing homes to achieve top “star” ratings. According to CMS, before this “recalibration” (dubbed Nursing Home Compare 3.0), about 80% of nursing homes received either a 4 or 5-star quality rating; now about 49% will receive these top star ratings. The number of nursing homes receiving one star has increased from 8.5% to 13% after the recalibration. CMS advises consumers to rely on multiple factors in selecting a nursing home, however, including star ratings, visits, and reputation.

CMS Plans Spring Rulemaking to Modify Meaningful Use Requirements

CMS has announced that it plans to issue regulations this spring to address provider concerns about the burden associated with compliance with Medicare and Medicaid Electronic Health Record (EHR) Incentive Program meaningful use requirements. Specifically, in a January 29, 2015 blog post by Patrick Conway, MD, Deputy Administrator for Innovation and Quality and CMS Chief Medical Officer, CMS announced that upcoming regulations would:

  • Realign hospital EHR reporting periods to the calendar year facilitate hospitals incorporation of 2014 Edition software into their workflows and better align with other CMS quality programs;
  • Modify other aspects of the program to reduce complexity and lessen providers’ reporting burdens; and
  • Reduce the EHR reporting period in 2015 to 90 days to accommodate these changes.

These changes are separate from another rulemaking expected to be released next month that would address the Stage 3 meaningful use criteria for 2017 and subsequent years.

CMS Adds Star Ratings to Dialysis Facility Compare

On January 22, 2015, the Centers for Medicare & Medicaid Services (CMS) added star ratings to the Dialysis Facility Compare (DFC) website, with a one- to five-star rating assigned based on performance on nine quality measures. CMS plans to update the star ratings annually beginning in October 2015. CMS also announced plans to add the dialysis facility Standardized Readmission Ratio (SRR) to the data available on the DFC website, although it will not be included in the star rating at this time. 

Medicare DMEPOS Competitive Bidding Window is Now Open

The bidding window is now open for the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program Round 2 Recompete and the National Mail-Order Recompete for diabetic testing supplies. Bids will be accepted until March 25, 2015. Other key dates to note:

  • Registration to bid will close on February 17, 2015. Only suppliers that have registered and received a user ID and password will be eligible to submit bids.
  • The deadline to participate in the covered document review process is February 23, 2015. Under this process, suppliers may submit their required hardcopy financial documents to the Competitive Bidding Implementation Contractor (CBIC) in advance of the close of the bid window; suppliers will be notified if any individual financial documents are missing and have an opportunity to submit the missing documents.

Additional details are available at the CBIC web site.  

CMS Guidance on Provider Timeframes for Responding to Additional Documentation Requests

CMS has updated the Medicare Program Integrity Manual to clarify that providers and suppliers have 45 days to produce documents in response to a pre-payment review Additional Documentation Request (ADR) issued by a Medicare Administrative Contractor (MAC) or Zone Program Integrity Contractors (ZPIC). MAC and ZPIC reviewers are instructed not to grant extensions to providers who need more time to comply with such requests; instead, claims must be denied if the requested documentation is not received by day 46.

CMS Announces DMEPOS/Home Health/Hospice RAC, Improvements to RAC Process

CMS has announced that it has awarded the Region 5 Recovery Audit contract to Connolly, LLC (although the General Accounting Office subsequently reported that a bid protest has been filed regarding this award). The purpose of this contract will be to identify improper Medicare payments for durable medical equipment (DME), orthotics, prosthetics, and supplies and home health/hospice (HH/H) claims and work with CMS and the DME and HH/H MACs to adjust claims to recoup overpayments and pay underpayments. CMS observes that this award marks the beginning of the new Recovery Audit contracts, and it is the first contract to incorporate a series of changes intended to reduce the provider burden and increase program transparency (e.g., ADR limits, RAC accuracy threshold).

CMS Revises Down 1st Quarter 2015 Medicare Physician Fee Schedule (MPFS) Conversion Factor

CMS has posted a January 2015 release of the National Physician Fee Schedule Relative Value File, reflecting a conversion factor (CF) of $35.7547 – down slightly from the $35.8013 included in the 2015 final MPFS rule published on November 12, 2014.  CMS is expected to publish a notice explaining the reasons for the revised CF.  CMS had previously announced that it is holding Medicare physician claims for services furnished during the first two weeks of 2015 because of unspecified errors found in the MPFS final rule.  The claims hold is not expected to actually disrupt cash flow since clean electronic claims are not processed for 14 days anyway.

Note that the new CF applies only to services provided during the first three months of 2015, as a result of a temporary patch included in the Protecting Access to Medicare Act (PAMA) of 2014.  On April 1, 2015, the conversion factor is scheduled to be adjusted according to the statutory Sustainable Growth Rate (SGR) formula, resulting in an estimated 21.2% reduction -- unless Congress steps in and establishes an alternative conversion factor or otherwise reforms the SGR formula. Congress is expected to attempt to adopt a measure to prevent the scheduled April 1 SGR reduction from taking place.

CMS Releases 2015 Medicare Clinical Lab Fee Schedule Update

CMS has posted the 2015 update to the Medicare clinical laboratory fee schedule files

CMS Removes Seven Medicare National Coverage Determinations, Leaving Coverage to MACs

Yesterday CMS posted a Final Decision Memorandum for the Expedited Removal of National Coverage Determinations (NCDs).  By way of background, in an August 7, 2013 Federal Register notice (78 FR 48164), CMS established an expedited process for removing NCDs under certain circumstances, such as when they are no longer contain clinically pertinent or when the items or services are used infrequently by beneficiaries. Removal of an NCD does not necessarily result in noncoverage; instead, it allows the local Medicare Administrative Contractors (MACs) to determine coverage.

CMS reviewed NCDs that have not been reviewed in 10 years in order to evaluate the continued need for those policies to remain active on a national scale, and on November 27, 2013 CMS published for public comment the first list of NCDs proposed for removal. After review of public comments, CMS is now removing the following NCDs from the NCD Manual, effective December 18, 2014:

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CMS Announces Timeline for Next Phase of DMEPOS Competitive Bidding

CMS has announced its detailed timeline for recompeting the supplier contracts awarded under Round 2 of the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program and the National Mail-Order diabetic testing supplies competition. All current Round 2 and National Mail-Order diabetic testing supplies contracts will be up for rebidding. The current contract period expires on June 30, 2016; the new contracts will begin on July 1, 2016. The first key date in the recompete cycle is December 18, 2014, when supplier registration for bidding opens, and the actual bid window opens on January 22, 2015. The full timeline is as follows (note that dates are subject to change):

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CMS Posts January 2015 Update to Medicare Part B Drug Pricing Files

CMS has posted the January 2015 update to the Medicare average sales price (ASP) drug pricing files, which contain the payment amounts that CMS will use to pay for Part B covered drugs for the first quarter of 2015. CMS notes that prices for the top Part B drugs decreased by 0.1 % on average this quarter, and prices changed 2% or less for 26 of the top 50 higher-volume drugs.

CMS Delaying Enforcement of Medicare Part D Drug Prescriber Enrollment Requirements

CMS has announced that it is delaying a provision of its 2015 Medicare Advantage/Medicare Part D final rule, published on May 23, 2014, that requires physicians and other eligible professionals who prescribe Part D drugs to be enrolled in Medicare (or have a valid opt-out affidavit on file) for their prescriptions to be covered under Medicare Part D. While the final rule stated that the effective date for this requirement would be June 1, 2015, CMS has announced that it is delaying enforcement of this provision until December 1, 2015. CMS notes that Part D drug prescribers must submit their Medicare enrollment applications or opt-out affidavits to their Medicare Administrative Contractors by June 1, 2015 to provide sufficient processing time and prevent prescription drug claims from being denied beginning December 1, 2015.

CMS Issues Final Medicare Coverage with Evidence Development (CED) Guidance

On November 20, 2014, CMS released its final Medicare coverage document entitled “Guidance for the Public, Industry, and CMS Staff: Coverage with Evidence Development.”  CED policy provides the framework for Medicare coverage of items or services on the condition that they are furnished in the context of approved clinical studies or with the collection of additional clinical data. CMS notes that the CED process “can expedite earlier beneficiary access to innovative technology while ensuring that systematic patient safeguards” are in place. The final guidance describes, among other things, the history of CED, its statutory basis, governing principles, requirements for studies under the CED framework, coverage of control groups in CED studies, and transparency of such studies. CMS also responds to public comments received on a draft guidance document published on November 12, 2012. For instance, CMS notes that it has deleted a previous statement that it expects to use CED infrequently, since technology is being presented to the agency for coverage earlier in the technology lifecycle, and requesters more frequently ask CMS to consider using CED for their particular technology. CMS also agrees with commenters that CED should not be used when other forms of coverage are justified, should not duplicate efforts of other agencies or existing medical evidence, and should generally expand access to technologies. CMS also clarified that Medicare Administrative Contractors may use LCDs to determine coverage of items and services to the extent that they do not conflict with national Medicare policy.

CMS Update on Status of Final Medicaid FULs

CMS has announced that while it still has no fixed date for releasing finalized Affordable Care Act (ACA) federal upper limits (FUL) for multiple source prescription drugs, it intends to release the finalized ACA FULs at or about the same time that it publishes a final rule pertaining to Medicaid reimbursement for covered outpatient drugs under the ACA. According to the latest unified agenda, CMS now expects to issue that rulemaking in April 2015. In the interim, CMS will continue to post the draft monthly ACA FUL files.

CMS Releases 2015 Medicare DMEPOS Fee Schedule

CMS has released the Medicare DMEPOS fee schedule files that are effective January 1, 2015.  The DMEPOS fee schedule update factor for 2015 is 1.5%. 

CMS to Expand Nursing Home MDS Focused Surveys

In mid-2014, state survey agencies and CMS piloted a short-term focused survey in five states to assess nursing home Minimum Data Set, Version 3.0 (MDS 3.0) coding practices and its relationship to resident care. According to a CMS memo to state survey agencies, these surveys enhanced surveyors’ ability to identify errors and deficiencies, such as inaccuracies related to staging and documentation of pressure ulcers, the classification of antipsychotic drugs, and coding regarding the use of restraints. CMS therefore announced that it plans to expand these surveys nationwide in 2015. The scope of some or all of the focused surveys also will be expanded to include an assessment of the staffing levels of nursing facilities. Specifically, the assessment is intended to verify the staffing data self-reported by the nursing home and identify changes in staffing levels throughout the year.

CMS Updates Outpatient Therapy Caps for 2015

CMS has announced that the CY 2015 Medicare outpatient therapy limit is $1,940 for physical therapy and speech-language pathology combined and $1,940 for occupational therapy. The therapy cap exceptions process was extended through March 31, 2015 by the Protecting Access to Medicare Act of 2014.

Older Entries

November 18, 2014 — CMS Delaying Enforcement of HIPAA Health Plan Enumeration/Health Plan Identifier Regulations

November 12, 2014 — CMS Releases 2015 HCPCS Files

November 6, 2014 — FDA Revises Guidance Defining Delays, Denials, Limits and Refusals of a Drug Inspection

October 28, 2014 — CMS Launches "Transforming Clinical Practice Initiative"

October 28, 2014 — CMS Announces ACO "Investment Model" Initiative to Support Care Coordination Nationwide

October 28, 2014 — CMS Solicits Suggestions for Potential PQRS Measures

October 28, 2014 — CMS Releases Medicare Advantage/Drug Plan Quality Data, Enforcement Statistics

October 28, 2014 — Update on CMS Medicare Appeals Administrative Agreement Offer

October 27, 2014 — Update on Sunshine Act "Open Payments" Public Data Review and Data Correction Deadline

October 10, 2014 — CMS Releases Preliminary Determinations for New 2015 Clinical Laboratory Fee Schedule Codes

October 8, 2014 — CMS to Revise Five Star Quality Rating System for Nursing Homes

October 8, 2014 — CMS Launches "Open Payments" Public Database; Usability Concerns Remain

October 6, 2014 — RACs Identified $3.75 Billion in Improper FFS Medicare Payments in FY 2013

October 2, 2014 — CMS Seeks Input on Potential Delivery Innovations in Medicare Part D, Medicare Advantage, & Other Programs

September 11, 2014 — CMS Updates Medicare Part B Drug Pricing Files

September 8, 2014 — Medicare Ambulance Update Factor for CY 2015

September 4, 2014 — CMS Offers Settlement to Acute Care Hospitals, CAHs to Resolve Patient Status Denial Appeals

August 28, 2014 — More Changes to Sunshine Act "Open Payments" Timeline

August 21, 2014 — CMS Fingerprint-Based Background Checks are Underway - Impacting "High-Risk" Providers and Suppliers

August 20, 2014 — CMS Revises Sunshine Act "Open Payments" System Review/Dispute Deadlines Amid Concerns about Data Accuracy

August 19, 2014 — CMS Seeks Innovative Models on Beneficiary Engagement and Behavioral Insights

August 12, 2014 — CMS Again Extends Moratoria on Enrollment of HHAs, Ambulance Suppliers in Designated Areas

August 12, 2014 — Medicare Intravenous Immune Globulin (IVIG) Demonstration Launched

August 12, 2014 — CMS to Restart RAC Reviews

August 12, 2014 — Sunshine Act "Open Payments" System Off to Rocky Start as Data Discrepancies Force System Off-Line

July 24, 2014 — Revised CMS Policy on Medicare Part D Drugs for Hospice Enrollees

July 24, 2014 — Sunshine Act Open Payments System Review/Dispute Process Underway

July 17, 2014 — CMS Announces Plans for Medicare DMEPOS Competitive Bidding Round 2 Recompete and National Mail-Order Recompete

July 2, 2014 — CMS Proposes Discontinuing 2 HCPCS Codes under New Demonstration

June 25, 2014 — HHS Provides Update on ACA Insurance Costs and Choices, Announces Management Changes

June 25, 2014 — CMS Adds MAC/RAC "Provider Relations Coordinator" for Auditor Process Issues

June 25, 2014 — CMS Plans Medicare Quality "Star" Ratings for Hospitals, Dialysis Facilities, Home Health

June 25, 2014 — CMS Releases Updated Hospital Charge Data, New Chronic Conditions & Geographic Variations Files

June 12, 2014 — CMS Releases July 2014 Medicare Part B Drug ASP Update

June 6, 2014 — Is anybody home? Medicare contractors on the prowl for DMEPOS supplier violations of posted business hours and other physical facility standards.

June 2, 2014 — CMS Abandons Plans to Finalize ACA Medicaid Drug Pricing Policy in July 2014

June 2, 2014 — CMS Announces New Public Comment Process on Requests to Discontinue HCPCS Codes

June 2, 2014 — HHS Launches Second Round of State Innovation Models Initiative

May 23, 2014 — CMS Extends Partial ICD-9-CM and ICD-10 Code Freeze to Reflect Transition Delay

May 15, 2014 — CMS to Implement Ordering/Referring Denial Edits for HHA Certifying Physicians, Effective July 1, 2014

May 14, 2014 — CMS Announces Reforms to Quality Improvement Organization Program

May 14, 2014 — CMS Extends "Hardship Exemptions" Policy for Health Insurance Purchasers

April 28, 2014 — CMS Announces Changes to Comprehensive End-Stage Renal Disease (ESRD) Care Initiative

April 28, 2014 — CMS Offers Guidance to Hospitals and States Ahead of DSH Compliance Audits

April 28, 2014 — CMS Posts First Medicare Inpatient Psychiatric Facility Quality Data

April 28, 2014 — CMS Issues Call for PQRS Quality Measures

April 16, 2014 — CMS to Implement Fingerprint-Based Background Checks for High-Risk Providers and Suppliers in 2014

April 10, 2014 — Will Physician Payment Sunshine Act Data Usher in a New Era of False Claims Act Litigation?

April 9, 2014 — CMS Releases Physician-Specific Medicare Charge/Payment Data

April 9, 2014 — CMS Announces Final 2015 Medicare Advantage/Part D Drug Plan Rates and Policies

April 8, 2014 — CMS Seeking Comments on Supervision Levels for Select Hospital Outpatient Services

April 8, 2014 — HHS Releases HIPAA Security Risk Assessment Tool

April 8, 2014 — CMS Extends Deadline for Individuals to Enroll in Health Insurance through Exchanges

March 25, 2014 — CMS Finalizes 2014 Policy on Medicare Payment for Hospice Enrollees' Drug Expenses

March 24, 2014 — CMS Releases Subregulatory Guidance on ACA Insurance Coverage, Exchange Issues

March 20, 2014 — CMS Expands Medicare EHR "Meaningful Use" Hardship Exception to Cover Vendor Issues

March 20, 2014 — Medicare Paper Claims Must Be Submitted on Revised 1500 Form By April 1, 2014

March 20, 2014 — Two-Midnight Inpatient Admissions Policy Guidance

March 19, 2014 — CMS Posts April 2014 Medicare Part B Drug ASP Files

March 18, 2014 — "Medicare Care Choices Model" to Allow Certain Hospice Patients to Seek Curative Care

March 4, 2014 — CMS Announces RAC Audit "Pause," Upcoming RAC Program Reforms

March 4, 2014 — CMS Posts Final HIPAA Administrative Simplification Transaction Testing Checklists

March 4, 2014 — CMS Continues to Modify Implementation of 2-Midnight Inpatient Admissions Policy

March 3, 2014 — CMS Proposes 2015 Payment, Policy Updates for Medicare Advantage and Drug Plans

March 3, 2014 — CMS Invites Suggestions for Advanced Diagnostic Imaging Quality/Safety Regulations

March 3, 2014 — CMS to Allow Retroactive ACA Insurance Subsidies for Certain Non-Marketplace Plans

February 18, 2014 — CMS Issues Draft Guidance for Qualified Health Plan Issuers for 2015

February 13, 2014 — CMS Considering Innovative Episode-Based Payment Models for Outpatient Specialty Practitioner Services

February 13, 2014 — CMS Again Extends "Probe & Educate" Phase for 2-Midnight Inpatient Admissions Criteria Implementation; Clarifies Physician Certification Requirements

February 12, 2014 — CMS Outlines 2013 "Sunshine Act" Open Payments Program Registration/Data Submission Process

January 15, 2014 — CMS Loosens Restrictions on Disclosure of Physician-Specific Medicare Payment Data

January 7, 2014 — CMS Steps Up Efforts Aimed at "Recalcitrant" Medicare Providers and Suppliers

January 7, 2014 — CMS Requests Feedback on ACO Initiatives

January 7, 2014 — CMS Revises Hospital Equipment Maintenance Requirements

January 7, 2014 — Hardship Exemption for Individuals with Cancelled Insurance Policies

January 6, 2014 — CMS Invites Comments on Medicare Payment for Hospice Enrollees' Drug Expenses

December 12, 2013 — CMS Releases 2014 Medicare DMEPOS Fee Schedule

December 10, 2013 — CMS Blog Post Announces Delay in Electronic Health Record (EHR) Incentive Program "Stage 3" Meaningful Use Start

December 10, 2013 — Final 2014 Medicare Clinical Lab Rates Set

December 10, 2013 — 2014 HCPCS Update Posted

December 10, 2013 — Updated Medicare Part B Drug Files Released

December 10, 2013 — CMS Proposes Removing 10 Medicare National Coverage Policies

December 9, 2013 — CMS Announces Plans to Finalize ACA Medicaid Drug Pricing Policy in July 2014

November 25, 2013 — CMS Releases Standard Consumer Notices under ACA Grandfathering/Transitional Policy

November 25, 2013 — CMS Letter to States on Quality Considerations for Medicaid and CHIP Integrated Care Models

November 14, 2013 — CMS Announces Medicare DMEPOS Bidding Round 1 Recompete Contract Suppliers

November 14, 2013 — CMS Guidance on Medicare Inpatient Hospital Admissions Two-Midnight Policy

November 14, 2013 — CMS Launches Virtual Research Data Center

November 14, 2013 — Applications for 2015 HCPCS Codes Due Jan. 3, 2014

November 12, 2013 — CMS "Phase 2" Ordering/Referral Denial Edits to Go Live on Jan. 6, 2014

November 11, 2013 — CMS Announces Inflation Update to "Sunshine Act" Reporting Thresholds for 2014

October 31, 2013 — CMS Expects Delay in Release of 2014 HCPCS Update and Final Coding Decisions

October 30, 2013 — Obama Administration Aligns Health Exchange Enrollment Deadline and "Shared Responsibility" Penalty Trigger

October 30, 2013 — IPPS New Technology Add On Applications for FY 2015 Due November 25

October 10, 2013 — CMS Limits Compliance Reviews under New "2 Midnight" Inpatient Admissions Policy

October 10, 2013 — CMS Posts Revised Gapfill Payments for New Molecular Pathology Codes; Reconsideration Requests Due Oct. 30, 2013

October 9, 2013 — CMS Sets 1% Payment Update for Medicare Ambulance Rates in 2014

October 8, 2013 — HHS OCR Releases HIPAA Privacy Rule Guidance Documents

October 7, 2013 — Medicare Rates to Fall by Average of 37% under DMEPOS Competitive Bidding "Round 1 Recompete" Contracts

September 17, 2013 — CMS Issues Guidance on Admission Order and Certification Requirements for Inpatient Admissions